title: Stereotactic radiosurgery in the treatment of brain metastases: the current evidence.
abstract: Chemotherapy has made substantial progress in the therapy of systemic cancer, but the pharmacological efficacy is insufficient in the treatment of brain metastases. Fractionated whole brain radiotherapy (WBRT) has been a standard treatment of brain metastases, but provides limited local tumor control and often unsatisfactory clinical results. Stereotactic radiosurgery using Gamma Knife, Linac or Cyberknife has overcome several of these limitations, which has influenced recent treatment recommendations. This present review summarizes the current literature of single session radiosurgery concerning survival and quality of life, specific responses, tumor volumes and numbers, about potential treatment combinations and radioresistant metastases. Gamma Knife and Linac based radiosurgery provide consistent results with a reproducible local tumor control in both single and multiple brain metastases. Ideally minimum doses of ≥18Gy are applied. Reported local control rates were 90-94% for breast cancer metastases and 81-98% for brain metastases of lung cancer. Local tumor control rates after radiosurgery of otherwise radioresistant brain metastases were 73-90% for melanoma and 83-96% for renal cell cancer. Currently, there is a tendency to treat a larger number of brain metastases in a single radiosurgical session, since numerous studies document high local tumor control after radiosurgical treatment of >3 brain metastases. New remote brain metastases are reported in 33-42% after WBRT and in 39-52% after radiosurgery, but while WBRT is generally applied only once, radiosurgery can be used repeatedly for remote recurrences or new metastases after WBRT. Larger metastases (>8-10cc) should be removed surgically, but for smaller metastases Gamma Knife radiosurgery appears to be equally effective as surgical tumor resection (level I evidence). Radiosurgery avoids the impairments in cognition and quality of life that can be a consequence of WBRT (level I evidence). High local efficacy, preservation of cerebral functions, short hospitalization and the option to continue a systemic chemotherapy are factors in favor of a minimally invasive approach with stereotactic radiosurgery.
authors.affiliation: Gamma Knife Center, Karolinska University Hospital, Stockholm, Sweden; Gamma Knife Centre, Bupa Cromwell Hospital, London, United Kingdom. Electronic address: bodo.lippitz@cromwellhospital.com.
authors.forename: Bodo
authors.initials: B
authors.lastname: Lippitz
authors.forename: Christer
authors.initials: C
authors.lastname: Lindquist
authors.forename: Ian
authors.initials: I
authors.lastname: Paddick
authors.forename: David
authors.initials: D
authors.lastname: Peterson
authors.forename: Kevin
authors.initials: K
authors.lastname: O'Neill
authors.forename: Ronald
authors.initials: R
authors.lastname: Beaney
mesh_terms: D001932:Brain Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D003131:Combined Modality Therapy; D006801:Humans; D011788:Quality of Life; D016634:Radiosurgery; D016896:Treatment Outcome; D014916:Whole-Body Irradiation
keywords: Brain metastases; Gamma Knife; Linac; Radiosurgery; Treatment results